Provider Demographics
NPI:1104963552
Name:BULLOCK, LUCILYN ANN (PA-C)
Entity type:Individual
Prefix:MS
First Name:LUCILYN
Middle Name:ANN
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:TALLMADGE
Mailing Address - State:OH
Mailing Address - Zip Code:44278-2011
Mailing Address - Country:US
Mailing Address - Phone:330-630-9726
Mailing Address - Fax:330-634-2194
Practice Address - Street 1:60 NORTH AVE
Practice Address - Street 2:
Practice Address - City:TALLMADGE
Practice Address - State:OH
Practice Address - Zip Code:44278-2011
Practice Address - Country:US
Practice Address - Phone:330-670-4242
Practice Address - Fax:330-670-4241
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50-000779363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHPA13284Medicare PIN